coding for thoracotomy, my doctor "opened" the chest so other surgeron could work
operative note:
what are my cpt codes? my doctor "opened" the chest so other surgeon could do his surgery......
COSURGEONS: Dr. Harlan J. Bruner and Dr. Chris Malone.
PREOPERATIVE DIAGNOSIS: Metastatic fracture and collapse of T11 vertebral body.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE: Left lateral thoracotomy, resection of 10th rib, T11 corpectomy with fusion and instrumentation. Please see Dr. Bruner's dictation for the majority of the procedure.
DESCRIPTION: After having been placed on the operating table in supine position and placement of appropriate monitoring lines, general endotracheal anesthesia was induced. A single lumen endotracheal tube was placed. At this point then the patient was turned in the full right lateral decubitus position and secured laterally with axillary roll in place. Fluoroscopy was used to externally mark the site of the fracture. At this point then the left chest laterally was prepped and draped in a sterile fashion. Appropriate time-out was taken and a left lateral thoracotomy was performed through the ninth intercostal space. The 10th rib was fully excised. The periosteum was stripped and the rib was removed in its entirety. Next, the posterior pleura was opened longitudinally along the easily palpated vertebral bodies and the intravertebral space between T11 and T12 was tentatively identified. A spinal needle was placed in this disc space and fluoroscopy again confirmed its positioning at the lower edge of the fracture. Discussed was carried
posteriorly. The aorta was swept anteriorly. The vascular bundles over the body of T11 and T12 were taken with clips and controlled with Hemoclips. Once good exposure was achieved at the fracture site, fluoroscopy again confirmed appropriate placement and corpectomy and stabilization was done by Dr. Bruner. After full instrumentation, hemostasis was achieved. Operative field was relatively dry. The pleura was loosely reapproximated over the side plate and a 15 mm fluted Jackson-Pratt drain was placed posteriorly along the site. This was brought out through a separate incision anteriorly. The ribs were reapproximated with interrupted #1 Tevdek sutures. The muscle layers were reapproximated with 0 PDS. Subcutaneous tissue was closed with 3-0 PDS and the skin was closed with skin staples. The patient was then turned back to the supine position and taken to the
Post-Anesthesia Care Unit in satisfactory and stable condition.
operative note:
what are my cpt codes? my doctor "opened" the chest so other surgeon could do his surgery......
COSURGEONS: Dr. Harlan J. Bruner and Dr. Chris Malone.
PREOPERATIVE DIAGNOSIS: Metastatic fracture and collapse of T11 vertebral body.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE: Left lateral thoracotomy, resection of 10th rib, T11 corpectomy with fusion and instrumentation. Please see Dr. Bruner's dictation for the majority of the procedure.
DESCRIPTION: After having been placed on the operating table in supine position and placement of appropriate monitoring lines, general endotracheal anesthesia was induced. A single lumen endotracheal tube was placed. At this point then the patient was turned in the full right lateral decubitus position and secured laterally with axillary roll in place. Fluoroscopy was used to externally mark the site of the fracture. At this point then the left chest laterally was prepped and draped in a sterile fashion. Appropriate time-out was taken and a left lateral thoracotomy was performed through the ninth intercostal space. The 10th rib was fully excised. The periosteum was stripped and the rib was removed in its entirety. Next, the posterior pleura was opened longitudinally along the easily palpated vertebral bodies and the intravertebral space between T11 and T12 was tentatively identified. A spinal needle was placed in this disc space and fluoroscopy again confirmed its positioning at the lower edge of the fracture. Discussed was carried
posteriorly. The aorta was swept anteriorly. The vascular bundles over the body of T11 and T12 were taken with clips and controlled with Hemoclips. Once good exposure was achieved at the fracture site, fluoroscopy again confirmed appropriate placement and corpectomy and stabilization was done by Dr. Bruner. After full instrumentation, hemostasis was achieved. Operative field was relatively dry. The pleura was loosely reapproximated over the side plate and a 15 mm fluted Jackson-Pratt drain was placed posteriorly along the site. This was brought out through a separate incision anteriorly. The ribs were reapproximated with interrupted #1 Tevdek sutures. The muscle layers were reapproximated with 0 PDS. Subcutaneous tissue was closed with 3-0 PDS and the skin was closed with skin staples. The patient was then turned back to the supine position and taken to the
Post-Anesthesia Care Unit in satisfactory and stable condition.